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Impact of Cerebral Autoregulation Monitoring in Cerebrovascular Disease: A Systematic Review

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Abstract

Cerebral autoregulation (CA) prevents brain injury by maintaining a relatively constant cerebral blood flow despite fluctuations in cerebral perfusion pressure. This process is disrupted consequent to various neurologic pathologic processes, which may result in worsening neurologic outcomes. Herein, we aim to highlight evidence describing CA changes and the impact of CA monitoring in patients with cerebrovascular disease, including ischemic stroke, intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (aSAH). The study was preformed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. English language publications were identified through a systematic literature conducted in Ovid Medline, PubMed, and Embase databases. The search spanned the dates of each database’s inception through January 2021. We selected case–control studies, cohort observational studies, and randomized clinical trials for adult patients (≥ 18 years) who were monitored with continuous metrics using transcranial Doppler, near-infrared spectroscopy, and intracranial pressure monitors. Of 2799 records screened, 48 studies met the inclusion criteria. There were 23 studies on ischemic stroke, 18 studies on aSAH, 5 studies on ICH, and 2 studies on systemic hypertension. CA impairment was reported after ischemic stroke but generally improved after tissue plasminogen activator administration and successful mechanical thrombectomy. Persistent impairment in CA was associated with hemorrhagic transformation, malignant cerebral edema, and need for hemicraniectomy. Studies that investigated large ICHs described bilateral CA impairment up to 12 days from the ictus, especially in the presence of small vessel disease. In aSAH, impairment of CA was associated with angiographic vasospasm, delayed cerebral ischemia, and poor functional outcomes at 6 months. This systematic review highlights the available evidence for CA disruption during cerebrovascular diseases and its possible association with long-term neurological outcome. CA may be disrupted even before acute stroke in patients with untreated chronic hypertension. Monitoring CA may help in establishing individualized management targets in patients with cerebrovascular disease.

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Acknowledgements

We sincerely thank Ms. Claire Levine, MS, ESL (Johns Hopkins University), for her diligent proofreading of this article. This article was prepared while Dr. Rebecca Gottesman was employed at the Johns Hopkins University School of Medicine. The opinions expressed in this article are the authors’ own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.

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Authors and Affiliations

  1. Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Mais Al-Kawaz

  2. Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Mais Al-Kawaz, Sung-Min Cho & Jose I. Suarez

  3. Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Sung-Min Cho & Jose I. Suarez

  4. Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Jose I. Suarez

  5. Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Program, National Institutes of Health, Bethesda, MD, USA

    Rebecca F. Gottesman

  6. Division of Stroke and Neurocritical Care, Stanford University, Palo Alto, CA, USA

    Lucia Rivera-Lara

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Contributions

Drs. MAK and LRL had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the analysis. Study concept and design: MAK, SMC, LRL. Acquisition, analysis, or interpretation of data: MAK, LRL. Drafting of the manuscript: MAK, LRL. Critical revision of the manuscript for important intellectual content: MAK, SMC, RFG, JIS, LRL. Analysis: MAK, LRL. Study supervision: LRL.

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Correspondence to Mais Al-Kawaz.

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Conflict of interest

Dr. Al-Kawaz, Dr. Cho, Dr. Suarez, and Dr. Rivera-Lara have nothing to disclose. Dr. Gottesman was a former associate editor for the journal Neurology but has no other disclosures.

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This manuscript complies with all instructions to authors. The authorship requirements have been met and the final manuscript was approved by all authors. The manuscript has not been published elsewhere and is not under consideration by another journal. No IRB was required as this manuscript is a review article. This study also conforms to the Preferred Reporting Items for Systematic Reviews (PRISMA) Guidelines.

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Al-Kawaz, M., Cho, SM., Gottesman, R.F. et al. Impact of Cerebral Autoregulation Monitoring in Cerebrovascular Disease: A Systematic Review. Neurocrit Care 36, 1053–1070 (2022). https://doi.org/10.1007/s12028-022-01484-5

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